District of Columbia

Department of Health Care Finance

Provider Data Management System and Service

(PDMS) Project

Summary of Affordable Care Act Changes to Provider

Screening and Enrollment

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42 CFR 455 Subpart E – Provider Screening and Enrollment

What does CFR stand for?

CFR or Code of Federal Regulations is an annual codification of the

general and permanent rules published in the Federal Registry by the

executive departments and agencies of the Federal Government.

The purpose of the CFR is to present the official and complete text of

agency regulations in one organized publication and to provide a

comprehensive and convenient reference for all those who may

need to know the text of general and permanent Federal regulations.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.400 Purpose

This subpart implements section 1866(j), 1902(a)(39),

1902(a)(77), and 1902(a)(78) of the Act. It sets forth District

plan requirements regarding the following:

(a) Provider screening and enrollment requirements.

(b) Fees associated with provider screening.

(c) Temporary moratoria on enrollment of providers.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.405 District plan requirements

The District of Columbia plan must provide that the requirements of 455.410 through 455.450 and 455.470 are met.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.410 Enrollment and screening of providers

a) The District Medicaid agency must require all enrolled providers

to be screened under to subpart.

b) The District Medicaid agency must require all ordering or

referring physicians or other professionals providing services

under the District plan or under a waiver of the plan to be

enrolled as participating providers.

c) The District Medicaid agency may rely on the results of the provider screening performed by any of the following:

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42 CFR 455 Subpart E – Provider Screening and Enrollment

• Medicare contractors

• Medicaid agencies or

• Children’s Health Insurance Programs of other States

455.412 Verification of provider licenses

The District Medicaid agency must –

a) Have a method for verifying that any provider purporting

to be licensed in accordance with laws of any

State/District of Columbia is licensed by such District.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.412 Verification of provider licenses (cont.)

b) Confirm that the provider’s license has not expired and that there are no current limitations on the provider’s license.

455.414 Revalidation of enrollment

The District Medicaid agency must revalidate the enrollment of all

providers regardless of provider type at least every 5 years.

However, the District requires DME providers to re-enroll every 3

years.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.416 Termination or denial of enrollment

The District Medicaid agency:

a) Must terminate the enrollment of any provider where any

person with a 5 percent or greater direct or indirect ownership

interest in the provider did not submit timely and accurate

information and cooperate with any screening methods required

under this subpart.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.416 Termination or denial of enrollment (cont.)

b) Must deny enrollment or terminate the enrollment of any

provider where any person with a 5 percent or greater direct or

indirect ownership interest in the provider has been convicted of

a criminal offense related to that person’s involvement with the Medicare, Medicaid, or title XXI program in the last 10 years,

unless the District Medicaid agency determines that denial or

termination of enrollment is not in the best interest s of the

Medicaid program and the District Medicaid agency documents

that determination in writing.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.416 Termination or denial of enrollment (cont.)

(c) Must deny enrollment or terminate the enrollment of any

provider that is terminated on or after January 1, 2011, under

the title XVIII of the Act or under the Medicaid program or CHIP

of any other State.

(d) Must terminate the provider’s enrollment or deny enrollment of the provider if the provider or a person with an ownership or

control interest or who is an agent or managing employee of

the provider fails to submit timely or accurate information,

unless the District Medicaid agency determines that

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42 CFR 455 Subpart E – Provider Screening and Enrollment

termination or denial of enrollment is not in the best Interests

of the Medicaid program and the District Medicaid agency

documents that determination in writing.

(e) Must terminate or deny enrollment if the provider, or any

person with a 5 percent or greater direct or indirect

ownership interest in the provider, fails to submit sets of

fingerprints in a form and manner to be determined by the

Medicaid agency within 30 days of a CMS or a District

Medicaid agency request, unless the District Medicaid

agency determines that termination or denial of

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42 CFR 455 Subpart E – Provider Screening and Enrollment

enrollment is not in the best interests of the Medicaid

agency documents that determination in writing.

(f) Must terminate or deny enrollment if the provider fails to

permit access to provider locations for any site visits under

455.432, unless the District Medicaid agency determines

that termination or denial of enrollment is not in the best

interests of the Medicaid program and the District Medicaid

agency documents that determination in writing.

(g) May terminate or deny the provider’s enrollment if CMS or the District Medicaid agency –

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42 CFR 455 Subpart E – Provider Screening and Enrollment

(1) Determines that the provider has falsified any information provided on the application; or

(2) Cannot verify the identity of any provider applicant.

455.420 Reactivation of provider enrollment

After deactivation of a provider enrollment number for any reason, before the provider’s enrollment may be reactivated, the District Medicaid agency must re-screen

the provider and require payment of associated provider

application fees under 455.460.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.422 Appeal Rights

The District Medicaid agency must give providers

terminated or denied under 455.416, any appeal rights

available under procedures established by District law or

regulations.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.432 Site visits

The District Medicaid agency –

(a) Must conduct pre-enrollment and post-enrollment site visits

of providers who are designated as “moderate” or “high” categorical risks to the Medicaid program. The purpose of

the site visit will be to verify that the information submitted

to the District Medicaid agency is accurate and to determine

compliance with Federal and District enrollment

requirements.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

(b) Must require any enrolled provider to permit CMS, its

agents, its designated contractors, or the District Medicaid

agency to conduct unannounced on-site inspections of any

and all provider locations.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.434 Criminal background checks

The District Medicaid agency – (a) As a condition of enrollment, must require providers to

consent to criminal background checks including

fingerprinting when required to do so under District law

or by the level of screening based on risk of fraud, waste

or abuse as determined for that category of provider.

(b) Must establish categorical risk levels for providers and

provider categories who pose an increased financial risk

of fraud, waste or abuse to the Medicaid program.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.434 Criminal background checks (cont.)

(1) Upon the District Medicaid agency determining that a provider,

or a person with a 5 percent or more direct ownership interest

in the provider, meets the District Medicaid agency’s criteria hereunder for criminal background checks as a “high” risk to the Medicaid program, the District Medicaid agency will require

that each such provider or person submit fingerprints.

(2) The District Medicaid agency must require a provider, or any

person with a 5 percent or more direct or indirect ownership

interest in the provider, to submit a set of fingerprints, in a

form and manner to be determined by the District Medicaid

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42 CFR 455 Subpart E – Provider Screening and Enrollment

agency, within 30 days upon request from CMS or the District

Medicaid agency.

455.436 Federal database checks

The District Medicaid agency must do all of the following:

a) Confirm the identity and determine the exclusion status of

providers and any person with an ownership or control interest

or who is an agent or managing employee of the provider

through routine checks of Federal databases.

b) Check the Social Security !dministration’s Death Master File, the National Plan and Provider Enumeration System (NPPES), the

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42 CFR 455 Subpart E – Provider Screening and Enrollment

List of Excluded Individuals/Entities (LEIE), the Excluded Parties

List System (EPLS), and any such other databases as the

Secretary may prescribe.

(1) Consult appropriate databases to confirm identity upon

enrollment and reenrollment; and

(2) Check the LEIE and EPLS no less frequently than monthly.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.440 National Provider Identifier

The District Medicaid agency must require all claims for payment

for items and services that were ordered or referred to contain the

National Provider Identifier (NPI) of the physician or other

professional who ordered or referred such items or services.

455.450 Screening levels for Medicaid providers

A District Medicaid agency must screen all initial applications,

including applications for a new practice location, and any

applications received in response to a re-enrollment or revalidation

of enrollment request based on a categorical risk level of “limited”,

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42 CFR 455 Subpart E – Provider Screening and Enrollment

“moderate”, or “high”. If a provider could fit within more than one risk level described in this section, the highest level of screening is applicable.

a) Screening for providers designated as limited categorical risk.

When the District Medicaid agency designates a provider as a

limited categorical risk, the District Medicaid agency must do all

of the following: 1. Verify that a provider meets any applicable Federal

regulations, or District requirements for the provider type prior to making an enrollment determination.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.450 Screening levels for Medicaid providers (cont.)

2. Conduct license verifications, including State licensure verifications in States other than where the provider is enrolling, in accordance with 455.412.

3. Conduct database checks on a pre- and post-enrollment

basis to ensure that providers continue to meet the

enrollment criteria for their provider type, in accordance

with 455.436.

(b) Screening for providers designated as moderate categorical risk. When the District Medicaid agency designates a provider as a

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42 CFR 455 Subpart E – Provider Screening and Enrollment

“moderate” categorical risk, the District Medicaid agency must do both of the following:

1. Perform the “limited” screening requirements described in paragraph (a) of this section.

2. Conduct on-site visits in accordance with 455.432.

(c) Screening for providers designated as high categorical risk. When the District Medicaid agency designates a provider as a “high” categorical risk, the District Medicaid agency must do both of the following:

1. Perform the “limited” and “moderate” screening requirements described in paragraph (a) and (b) of this section.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

2. (i) Conduct a criminal background check; and (ii) Require submission of a set of fingerprints in accordance with 455.434.

(d) Denial or termination of enrollment. A provider, or any person

with 5 percent or greater direct or indirect ownership in the

provider, who is required by the District Medicaid agency or CMS to

submit a set of fingerprints and fails to do so may have its –

1. Application denied under 455.434; or

2. Enrollment terminated under 455.416.

(e) Adjustment of risk level. The District agency must adjust the categorical risk level from “limited” or “moderate” to “high” when any of the following occurs:

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42 CFR 455 Subpart E – Provider Screening and Enrollment

1. The District Medicaid agency imposes a payment suspension on

a provider based on credible allegation of fraud, waste or abuse,

the provider has an existing Medicaid overpayment, or the

provider has been excluded by the OIG or another State’s Medicaid program within the previous 10 years.

2. The District Medicaid agency or CMS in the previous 6 months lifted a temporary moratorium for the particular provider type and a provider that was prevented from enrolling based on the moratorium applies for enrollment as a provider at any time within 6 months from the date the moratorium was lifted.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.452 Other District screening methods

Nothing in this subpart must restrict the District Medicaid agency from establishing provider screening methods in addition to or more stringent than those required by this subpart.

455.460 Application fee

(a) Beginning on or after March 25, 2011, the District must collect the applicable application fee prior to executing a provider agreement from a prospective or re-enrolling provider other than either of the following:

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42 CFR 455 Subpart E – Provider Screening and Enrollment

1. Individual physicians or non-physician practitioners.

2. Providers who are enrolled in either of the following:

i. Title XVIII of the Act.

ii. !nother State’s title XIX or XXI plan. 3. Providers that have paid the applicable application fee to

i. A Medicare contractor; or ii. Another State.

(b) If the fees collected by a State agency in accordance with paragraph (a) of this section, exceed the cost of the screening program, the District agency must return that portion of the fees to the Federal government.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

455.470 Temporary moratoria

(a) (1) The Secretary consults with any affected District Medicaid

agency regarding imposition of temporary moratoria on enrollment

of new providers or provider types prior to imposition of the

moratoria, in accordance with 424.570 of this chapter.

(3) The District Medicaid agency will impose temporary

moratoria on enrollment of new providers or provider types

identified by the Secretary as posing an increased risk to the

Medicaid program.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

(3)(i) The District Medicaid agency is not required to impose such

a moratorium if the District Medicaid agency determines that

imposing a temporary moratorium would adversely affect

beneficiaries’ access to medical assistance. (ii) If the District Medicaid agency makes such determination, the District Medicaid agency must

notify the Secretary in writing.

(b) (1) The District Medicaid agency may impose temporary

moratoria on enrollment of new providers, or impose numerical

caps or other limits that the District Medicaid agency identifies as

having a significant potential for fraud, waste, or abuse and that the

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42 CFR 455 Subpart E – Provider Screening and Enrollment

Secretary has identified as being at high risk for fraud, waste, or

abuse.

(2) Before implementing the moratoria, caps, or other limits,

the District Medicaid agency must determine that its action would

not adversely impact beneficiaries’ access to medical assistance.

(3) The District Medicaid agency must notify the Secretary in

writing in the event the District Medicaid agency seeks to impose

such moratoria, including all details of the Moratoria; and obtain

the Secretary’s concurrence with imposition of the moratoria.

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42 CFR 455 Subpart E – Provider Screening and Enrollment

(c) (1) The District Medicaid agency must impose the moratorium

for an initial period of 6 months.

(2) If the District Medicaid agency determines that it is necessary, the District Medicaid agency may extend the moratorium in 6-month increments.

(3) Each time, the District Medicaid agency must

document in writing the necessity for extending the

moratorium.

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